NCLEX Practice Test

Which nursing actions should be included in the plan of care for a client with increased intracranial pressure? Select all that apply.

1. Administer a stool softener

2. Dim lights when not providing care

3. Elevate head on several pillows

4. Maintain body in midline position

5. Only perform oral suctioning when necessary

The correct answer is: Administer a stool softener

Administering a stool softener is an essential nursing action for a client with increased intracranial pressure (ICP). This is because straining during bowel movements can significantly elevate ICP. A stool softener helps prevent constipation and minimizes the risk of straining, thereby aiding in the overall management of intracranial pressure. In addition to this choice, dimming lights when not providing care is beneficial as it helps create a calm and less stimulating environment that can reduce agitation and stress for the patient, potentially stabilizing ICP. Maintaining the body in a midline position is also important for venous drainage and to prevent any positional increases in ICP. Elevating the head using multiple pillows might not be as effective as using a systematic elevation, which is typically more controlled at a 30-degree angle to facilitate cerebral venous return. Restricting oral suctioning to only when necessary is important to prevent excessive stimulation or discomfort that may lead to increased ICP, as suctioning can cause transient increases in intracranial pressure. In summary, proper management of stools, environmental control, body positioning, and careful suctioning practices are critical nursing actions to include in the care plan for a client with increased ICP.